%Stop Smoking Success Quiz%
%How motivated are you to stop smoking and likely to succeed?%

Name Email
On the scale below, how ready do you feel you are to stop smoking right now?
Since you first started smoking cigarettes how many serious attempts to quit smoking have you made that lasted longer than 24 hours?
How willing are you to have an open mind and try new ideas and things?
Have you been told by a doctor that you have any health concerns related to smoking(heart and circulation conditions, respiratory conditions, cancer, digestive, angina, etc.)?
Do you hide your smoking from family or friends?
On the below scale, how much do you experience feelings of social exclusion, or being an outcast because of your smoking?
How addicted do you feel you are to nicotine?
Do you know someone who has quit cold turkey before?
Has someone related to you died from a smoke related disease?
Are you open to new ideas and suggestions?
Do you believe people can make changes easily?
Do you believe you can successfully stop smoking with the right help?
Has anyone ever been able to convince you of a different perspective on a topic?
Do you feel you are always right about things or have a hard time seeing things from a different perspective? Which below, best describes you?
I will have support from friends and family in my life if I choose to quit smoking?
Can you imagine living your life as a non-smoker?
Other than yourself does anyone smoke in your presence at home or at work?
I use or can see how I could use other things rather than smoking to calm myself down in stressful situations?
On the below scale, how much do you experience low energy because of smoking?
Do you feel you are a rebel at heart?
Are you concerned with weight gain when you stop smoking?
During the past 3 months how many days did you not smoke any cigarettes?
Are you aware of and/or feel embarrassed or ashamed of smelling of smoke?
How long have you smoked?

How many cigarettes/packs do you smoke per day?

How long have you smoked?

Is there anything else you would like me to know about your smoking habit?